Why Patient Safety is Hard

What Do The Five Stages of Death & Dying Have to Do With Patient Safety It’s Not What You Think.

To start, I thought it might be helpful to pull out something I wrote quite some time ago. It was my thoughts on my first reactions to a report from the Institute of Medicine called “To Err is Human”. I was shocked at the suggestion that health care wasn’t safe. I really didn’t believe that this could be true! The healthcare system harming patients? What I initially wrote was long, so I will be breaking this up into several blog posts.

My Journey to Acceptance:

I have a confession to make. I believe that physicians are not always delivering the best quality of care and we make mistakes. The evidence of quality deficit as well as variability of health care delivery is overwhelming. It has been over six years since the Institute of Medicine (IOM) released To Err is Human: Building a Safer Health System¹ with the frightening claim that 98,000 people were dying as a consequence of medical errors. A recent article found that Americans receive medical care indicated by current research only 55 percent of the time.² Estimates exist that as many as 80,000 Americans perish each year because they do not receive appropriate, well proven, care for common conditions such as diabetes and hypertension.³ While these reports focus on under-use of medical care, over-use is also a problem leading to complications and increased cost.⁴ Along with these and many other reports that cast doubt on the quality of health care provided, evidence also exists which documents the enormous variation in the way health care is delivered. Researchers at Dartmouth University have been documenting large geographic variations in the use of health care resources by equivalent populations for almost three decades.⁵ Variability in the resources used for specific diseases might be appropriate if the increased resource utilization resulted in better outcomes, but this is not the case. Instead, in many cases increased resource utilization is linked to poorer outcomes.⁶ An analysis by the Hospital Quality Alliance (HQA) has found that the quality of hospital care varies across conditions within individual hospitals as well as by geographic region.⁷ It seems reasonable to conclude that, despite many amazing successes in patient care, we do not always provide the quality of care that we might wish. 

The response to this compelling research on the part of the medical profession has been encouraging, but does not seem to have reached the level of alarm that it merits. In fact, one of the few legislative actions taken last year by the senate was a bill to reform medical liability. This legislation would have greatly restricted the non-economic damages that patients could receive if they were harmed by medical actions. This legislation ultimately failed to pass the Senate, but it was widely supported by physicians and medical associations. While the individual merits of these bills may be argued, little comment was made about reasons people seek redress for injuries they perceive were caused by the medical system. Frivolous lawsuits do occur, and few physicians would argue that the medical liability system is terribly flawed. Yet, it is also true that some patients are profoundly harmed by medical errors. Thus, legislation that restricted the ability of patients to be compensated for outcomes that may have resulted from medical mishaps seem poorly conceived. When I asked physicians how they reconcile the concept that medical errors occur at an alarming rate with legislation that limits the ability of people to collect non-economic damages the most common answer I received was something to the effect of “I just do not believe that these errors are occurring. This is not what I see in my practice.”

 I was struck by how far apart I seemed to be from many of my colleagues. I have reluctantly come to the conclusion that medical errors occur and that they contribute to both the morbidity and mortality of patients. However, this acceptance did not come easily. It was only recently when reflecting on this journey that some of the steps I had taken seemed familiar. After some time I realized I had made my way through the familiar stages of death and dying that had been so eloquently been described by Elizabeth Kubler–Ross (Table 1). While I don’t want to be presumptuous, I thought I might share my journey. 

Table 1: Kubler-Ross’ five stages of dying

In her 1969 book, On Death and Dying [On Death & Dying, (Simon & Schuster/Touchstone), 1969] Swiss-born psychiatrist Elizabeth Kubler-Ross outlined the five stages of grief of someone who is dying: 
• Denial and isolation: “This is not happening to me.” 
• Anger: “How dare God do this to me.”
• Bargaining: “Just let me live to see my son graduate.”
• Depression: “I can’t bear to face going through this, putting my family through this.”
• Acceptance: “I’m ready, I don’t want to struggle anymore.”

References:

1. Institute of Medicine, To Err is Human: Building A Safer Health System (Washington, D.C.: National Academies Press, 1999
2. McGlynn EA, Asch SM, Adams J, et al.: The Quality of Health Care Delivered in the United States. N Eng J Med 2003; 348:2635-45
3. National Committee for Quality Assurance, State of Health Care Quality 2004 (Washington, D.C.: NCQA, Sept 2004
4. Bernstein, S.J., E.A. McGlynn, A.L. Siu, et al., “The Appropriateness of Hysterectomy. A Comparison of Care in Seven Health Plans. Health Maintenance Organization Quality of Care Consortium,” Journal of the American Medical Association 269(18):2398-402, May 12, 1993
5. Wennberg JE, Cooper MM, eds., The Quality of Medical Care in the United States: A Report on the Medicare Program, The Dartmouth Atlas of Health Care 1999 (Chicago: American Health Association Press, 1999)
6. Fisher ES, et al.: Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health service Research 2000; 34:1351-1362
7. Jha AK, Li Z, Orav EJ, et al.: Care in U.S. Hospitals – The Hospital Quality Alliance Program. N Eng J Med 2005; 353:265-74